Job Description
Social Worker
The Social Worker provides support to patients with complex health needs and are an integral part of our coordinated care team which includes physicians, nurse practitioners, nurses, care coordinators, social workers, dietitians, educators and pharmacists. The Strive Social Worker must be able to work successfully both in person and remotely via telephone or videoconferencing technologies. They will be assigned a patient census and will round on patients in a variety of clinical settings such as hospitals, SNFs, dialysis centers, and the patient’s home. The Strive Social Worker is responsible for addressing non-clinical barriers to care and screening for social determinants of health.
Essential Functions
Arrange, coordinate, monitor, evaluate, and advocate for support services to meet patient clinical, behavioral and social health needs
Provide counseling, education, and crisis intervention
Build a strong relationship with the patient and their family and then investigate the social factors that are influencing their health with empathy, trust, and compassion
Educate the patient and patient’s family on condition, treatment, and benefits of selected interventions
Collaborate with multidisciplinary treatment team including patients’ primary care providers, case managers, care coordinators, and others
Understand what the patient wants for his or her life and work to remove the barriers
Collaborate with the Nurse Practitioner to ensure clinical instructions are followed by the patient and the patient needs are communicated to the NP
Support and coach care team on effective identification of emotional and psychosocial health needs and promote sensitivity to mental health in their daily practice
Help patients locate and access community resources. Assist patients above and beyond making a referral. Social workers will help drive engagement with resources.
Educate the entire care team on community resources and pull together resource information so they can make simple referrals
Assess home environments to understand deeper issues impacting patient health
Get involved with patient’s adherence challenges and high risk situations (like high ER utilization) to solve for them
Develop collaborative relationships with dialysis unit social workers
Minimum Qualifications
Master’s degree in social work required
Licensed Clinical Social Worker Certificate
Minimum 5 years experience working in chronic disease management (e.g. internal medicine, renal, cardiac, pulmonary, or oncology care) or critical care setting
State specific licensure required
Visit patients in home environment
Preferred Qualification
Ability to develop and maintain patient relationships
Knowledge of surrounding community resources
Strong communication skills